Brain Magnetic Resonance Spectroscopy Findings in the Stroke‐like Migraine Attacks after Radiation Therapy (SMART) Syndrome

ABSTRACT A 41‐year‐old male presented with an acute onset of headache, confusion, seizures, and unilateral focal neurological deficit 25 years after receiving whole‐brain radiation therapy to treat a cerebellar medulloblastoma. Brain magnetic resonance imaging (MRI) demonstrated a thick unilateral parieto‐occipital cortical contrast enhancement. A diagnosis of “Stroke‐like Migraine Attacks after Radiation Therapy” (SMART) syndrome was made. Here, we describe the brain MR spectroscopy findings of SMART, showing a decrease in N‐acetyl‐aspartate and increased levels of creatine and choline, corresponding with neuronal destruction or transient neuronal impairment with mild nonspecific gliosis. The absence of a lactate peak suggests that mitochondrial dysfunction, vasospasm or ischemic mechanisms were not involved.